Thoracic Spine Compression FX

Thoracic Spinal Cord Compression Fx's commonly occur in the lower t-spine since the upper t-spine is stabilized by the rib cage attachments. Spinal cord compression fx's occur when the vertebral body of spinal cord collapse resulting in acute back pain that causes a decrease mobility and general health.

The most common motion that causes the vertebral body to collapse is a forward bend with downward pressure on the spinal column. Osteoporosis can also be a contributing factor to pts with t-spine compression fx's The osteoporotic t-spine can cause a pt's spine to form an exaggerated kyphotic curve of upper t-spine related to the back pain causing the shoulders to slump forward. Traumatic injuries such as an MVA, fall, or a forceful landing from a jump can all also cause t-spine compression fx's. Metastatic disease can also cause a t-spine compression fx. The spread of cancer to the vertebral body causes a weakening in the bony structure allowing a compression fx to present.

AP and Lateral radiographs are the best form of identifying t-spine compression fx's. This form of radiography is the best why to completely visualize the entire aspect of the vertebral body. Next, a multislice axial CT scan with reformats in the frontal and sagittal plane of the t-spine are useful to examine any pathology that may be affecting the spinal canal. MRI is used only in spinal cord compression fx pt's that have any resulting neurologic deficiencies. Lastly, an Nuclear Medicine bone scan may also be ordered to determine the age and nature of the t-spine compression fx.

Most t-spine compression fx are treated with pain medication, physical therapy, decreasing activity, bracing, and/or a form of surgical fixation.

Some t-spine compression fx may require the use of a vertebroplasty or kyphoplasty intervention. This procedure is done either in a surgical suite or in an interventional radiography suite. In a vertebroplasty, a medical grade cement is injected in the vertebral body at the site of the fx to stabilize the vertebrae in relieve pain. In a kyphoplasty, a balloon is inserted in the fx site in order to reinstate the original shape of the vertebral body, and then inject the medical grade cement into the vertebrae. This is also in efforts to rebuild the vertebral body to its original form and relieve pain.

http://www.csmc.edu/9466.html

http://emedicine.medscape.com/article/397896-overview

http://www.umm.edu/spinecenter/education/thoracic_compression_fractures.htm

JEFFERSON'S FX

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B

Image A:

www.arenachiropractic.com/StudyManual.html

Image B:

www.learningradiology.com

A Jefferson's FX is a result of a burst fracture to the closed ring of C1 (atlas). A Jefferson's FX most commonly results in at least 2 fractures of C1 because of the anatomical structure being a ring. These FX's often occur as a result of an axial loading impact to the skull.

There are three impact injuries that are responsible for the majority of all Jefferson FX's.

1-Diving into shallow water and hitting on head

2 -Hitting on head of roof of motor vehicle during an MVA

3 - Falls that result in landing on head

Depending on the injury, and the amount of impact on the head other additional injuries can accompany a Jefferson's FX.

1 - C2 FX

2 - Vertebral artery damage

3 - Cranial nerve defects in V, IX, X, and XI

4 - atlantooccipital dislocation

5 - transverse ligament fracture

Pt's who have a Jefferson's FX will present with neck pain, as a result of an injury. It is common for most all neck pain pt's to present with these symptoms; however, it is vital to rule out a Jefferson's FX promptly before any neurologically damage occurs as a result of an untreated Jefferson's FX. If a pt presents, and is positive for a Jefferson's FX and does have substantial neurological deficits. They will need to have a tracheostomy place to assist with respiratory needs.

Once a Jefferson's FX has been confirmed, and the severity of the FX has been decided, a

decision on the treatment that needs to take place is the next vital step for these patients

Depending on the severity of any additional symptoms in patients with Jefferson's FX, treatment then varies accordingly.

The first steps of treatment occur at the site of the injury. Airway, breathing, and circulation must first be assessed prior to moving the patient. If the airway and breathing are not working sufficiently - intubation must be performed without movement of the C-spine. At this point, it is also important to remember that these patients may have suffered a concussion or may be in shock and unable to report any neck pain. To be safe, it is a must to treat all patients as if there might be a spinal cord injury of some sort.

Next, cervical spine radiographs need to be performed in the ER. Usually this is a x-table lateral c-spine film to evaluate the alignment of the odontoid complex in relation to the remaining c-spine vertebra. This view is best to r/o any anterior dislocation. The odontoid view is also necessary to image to symmetry of the odontoid projection between the lateral masses of C2. If a lateral disruption overhangs the masses by more than 6.9mm a C1 FX is a established. Lastly, a CT may be used in addition to verify the Jefferson's FX with thin axial slices through the level of the base of the skull through C2. Angiography may also be needed to evaluate any vertebral vessel involvement.

The most common way to treat a Jefferson's FX is with a surgical fixation of a Halo collar and/or vest. This is the best way to provide for stable and reliable healing process. Depending on any other cervical spine resulting injuries, determines how/where the Halo/Vest will be fixated. The should be maintained safely in a structured stability collar until time of surgery. Traction is not recommended due to the risk of spinal cord damage. Once the patient is in the OR, it is vital to keep the neurological function of the patient monitored in order to verify that no additional injury has occurred. Post operatively, the patient will remain in the Halo for 8-12 weeks. They also should regularly be monitored with radiographs to verify the healing process.

http://emedicine.medscape.com/article/1263453-diagnosis

Vertebral Artery Dissection

http://www.mghradrounds.org/clientuploads/october_2006/2A_B_C.jpg

Vertebral Artery Disease(VAD) is the more common cause of strokes in patients under the age of 45. It is closely related to Coronary Artery disease, with the exception of the unique signs and symptoms. VAD is caused by an expanding hematoma in the vertebral artery vessel wall. It can arise spontaneously or as a secondary result of trauma.

In the United States, 20% of ischemic strokes in patients between 30-45 age years old are caused of VAD, and 10% of all VAD resulting in death. The common ratio of female to male is 3:1 with the presentation of VAD.

A typical presentation of a patient with VAD will present with:

Severe occipital heachache

Posterior nuchal pain

CNS dysfunction

Ipsilateral facial dysesthesia (pain and numbness) - Most common symptom
Dysarthria or hoarseness (cranial nerves [CN] IX and X)
Contralateral loss of pain and temperature sensation in the trunk and limbs
Ipsilateral loss of taste (nucleus and tractus solitarius)
Hiccups
Vertigo
Nausea and vomiting
Diplopia or oscillopsia (image movement experienced with head motion)
Dysphagia (CN IX and X)
Disequilibrium
Unilateral hearing loss

Contralateral weakness or paralysis (pyramidal tract)
Contralateral numbness (medial lemniscus)

Causes of VAD include either spontaneous or traumatic VAD. Causes of traumatic VAD include MVA, fall, or penetrating trauma. Several risk factors of Spontaneous VAD include:

Spinal manipulation
Yoga
Ceiling painting
Nose blowing
Minor neck trauma
Judo
Medical risk factors
Hypertension (48% in one series)
Oral contraceptive use
Chronic headache syndromes/migraines
Intrinsic vascular pathology
Fibromuscular dysplasia
Cystic medial necrosis
Female sex
Recent infection

Diagnosing VAD involves all of the following workup:

Lab work is done in anticipation of the need for anticoagulants. A PT, PTT, INR, and ESR are all blood levels that will need to be evaluated in order to safely administer any anticoagulants.

CT Scan, CTA, MRI, MRA, Ultrasound Vascular Duplex Scanning, Transcranial Dopler's, and LP's are all diagnostic imaging studies that vastly aid in the diagnosing and evaluation of possible VAD and the patients additional symptoms.

Once it is ruled that anticoagulants are safe to administer, it is the preferred method of treating VAD in the emergency room.. The anticoagulants are intended to prevent thrombogenic or embolic occlusion of the vertebrobasilar network and subsequent infarction of posterior CNS structures, brain stem, and cerebellum. All patient's first under go a CT scan of the head to rule out any subarachnoid hemorrhage. Additionally, once a VAD patient is deemed stable, a neurosurgery consult should be ordered.

http://emedicine.medscape.com/

Lipoma of the Neck

Axial contrast CT of the head and neck showing a fatty mass in the subcutaneous tissue in the back of the neck

Axial contrasted CT of the head and neck showing fat attenuating mass at the right side of the neck. The mass invades the right sternocleidomastoid muscle, and is an infiltrating lipoma.

http://imaging.consult.com/imageSearch?query=tissue&resultOffset=241

Lipoma of the neck

Lipomas are benign tumors that consist of mature fat cells. They are more commonly found in subcutaneous tissues, but rarely can be seen within internal structures. Lipomas are developmentally different from normal fat cells due to their increase in levels of lipoprotein lipase.

Physical presentation

Small in size - 2-10cm

Predominately in women

Often appear lobulated

Overlying skin remains unaffected and unattached to lipoma

Neck, Back, and Proximal extremities are most often affected

Rubbery in consistancy

CT with contrast of the head and neck are the preformed form of imaging a lipoma of the neck. It is also the best imaging modality to diagnosis the difference between lipomas and liposarcomas. If liposarcoma is questioned a fine needle aspiration should be performed using ultrasound sonography.

Surgical removal by surgical excision procedures and liposuction are commonly the preferred form of treatments for lipomas of the neck; however in some case medications such as IV and topical lidocaine, steroid, and analgesics are used as well.

It is vitally important to provide adequate follow up care and maintenance to lipomas of the neck because they have the ability to evolve into additional diseases such as:

Hibernomas

Lipoblastomas

Liposarcomas

Neurofibromas

Epidermoid cysts

Obesity

Sialadenitis

Goiter

Lymphatic tumor

Dermatofibromas

http://emedicine.medscape.com/article/1057855-diagnosis

Saccular Aneurysms

An aneurysm can be defined as dilatation's in the lumen of the vessels of the brain caused by a weakness of all vessel wall layers. A Saccular aneurysm has rounded-berry like projections commonly arising from the Circle of Willis or the middle cerebral artery. Saccular Aneurysms are most often congenital in origin which gradually developed over a period of time; and as arterial pressure increases it weakens and then ultimately balloons out the vessel wall. This happens most frequently at bifurcation points.


Most Saccular Aneurysms do not present with any manifestations until they have ruptured. However, once they rupture, it is most often fatal.



Causes and Conditions Related to Saccular Aneurysms:
Trauma
Cocaine abuse
High-Flow states associated with Fistulas.
Infections
Tumors
Conditions related with increased rates of Saccular Aneurysms.
Polycystic Kidney Disease.
Coarctation of the aorta
Anomalous vessels
FMD
Connective Tissue disorders
High-Flow States
Vascular Malformations
Spontaneous Dissections


Signs and symptoms of saccular aneurysms are closely related to that of every other intercranial aneursym.

Pt's often state having the worst headache of their lives.
Cranial neuropathies
vision loss
seizures
TIA

The greatest cause of death from Saccular Aneurysms result from either trauma or vasospasms which are often related to the use of vasodilators or anticoagulants.

As the result of a Saccular Aneurysm a Subarachnoid Hemorrhage can occur:

A Saccular Aneurysm that has resulted in a Subarcharnoid Hemorrhage is most commonly graded on the Hunt and Hess scale. This scale measures the clinical severity of the hemorrhage. It ranges from a 0-5 with 0 being no rupture and 5 being a deep coma with morbid appearance of presenting patient. The Fisher scale is also highly used among health care providers because it describes that amount of blood seen on a noncontrasted head CT. It ranges from a scale of 1 - 4 with 1 being no blood detected and 4 being intracerebral or intraventricular clots.

DX and TX

MRA
MRV
CTA - Head CT with and without Contrast.

The most common treatment option for Saccular Aneurysms is Cerebral Surgeries to remove the clot or in efforts to drain blood that may have occured from a rupture.

http://emedicine.medscape.com/article/252142-overview

Orbital Blowout Fx!

Medial Blowout Fx Inferior Blowout Fx

http://radiopaedia.org/articles/blow-out_fracture

Orbital blowout fx are usually the result of blunt force trauma to the orbital rim. Examples of this type of trauma would be contact with a baseball, a baseball bat, MVA, and a fist. In an orbital fx, the blunt force "blows" out the floor or adjacent wall of the rim of the orbit. In most cases, it usually occurs in the inferior floor of the orbit, or the medial wall of the orbit. Also, the nasal bones are usually broken as well especially when the blowout fx involves the medial wall of the orbit.

Symptoms of an Orbital Blowout Fx are:

Pain

Diplopia on an upward stare - related to involvement on orbital muscles.

Enophthalmos - related to increased swelling and preasure in the orbital globe.

Facial numbness - related to inferior orbital nerve

Nose bleed

Orbital hemorrhage may occur

Imaging the Orbits

CT with coronals and axials specifically.

MRI with coronals and axials specifically, be sure to use fat suppression technique during exam.

Xray in the waters position especially.

Tx for Orbital Blowout Fx

Surgical repair of orbital blowout fx when:

More than 1/2 of the orbit floor or wall is invovled

Diplopia does not quickly resolve itself

Enophthalmos >2mm

Surgical repair usually involved a form of bone graft, synthetic material, or plate to fix the hole in the orbital rim.

Orbital blowout fx that go untreated, and have significant obital muscle, optic nerve, and acute bone damage can lead to long term visual defects as well as enophthalmos.

http://www.learningradiology.com/

Pituitary Macroadenoma

http://www.mdanderson.org/images/macrodenoma.jpg

Additional images and radiology based information at (I thought it was interesting)!:
http://www.urmc.rochester.edu/SMD/rad/neurocases/Neurocase81.htm



Pituitary Macroadenoma is a a benign pituitary tumor of a size greater than 10mm. It must measure greater than 10mm to be considered a macroadenoma. If the tumor measures smaller than 10mm it would then be considered a pituitary microadenoma. The pituitary gland controls and regulates growth, metabolism, and reproduction in the human body.

Patients with pituitary macroadenoma may present with the following symptoms:

• weakness




• fatigue




• restlessness




• headaches




• nausea




• vomiting




• vertigo




• changes in hair growth




• changes in body weight




• loss of vision due to the macroadenoma compressing the optic nerve

Diagnosing a pituitary macroadenoma begins with the following tests being ordered by a physician. More common diagnosis processes include: blood tests, urine test, CT scans, and MRI scan; however some less common tests may include petrosal sinus samplings, and certain eye exams.Treating a pituitary macroadenoma include surgery to remove the tumor, radiation therapy to kill the tumor, and also a range of drug therapies depending on the patient's age and overall health. If left untreated, and depending on the hormone that the macroadenoma is secreting several additional diseases can develop such as: Cushing's disease, Acromegaly, Lack of menstruation, Abnormal production of breast milk, and even Diabetes Insipidus.